00090078 CITY OF CUPERTINO 60.3 RSBF BATTENS
BUILDING DIVISION PERMIT CONTRACTORdNFO IOOOp OGRESS
BUILDING ADDRESS: PERMITNO.
78
OWNER'S NAMII `t0 ROSE BLOSSOM OR zT " MASERARY x APPLICNI IONS A I: -
HONG SANITARY NO. M- 1.
C z eARCHITECUENGINEER: G v - BUILDING PERMIT UNH)
FOO PLUG ELECT' PLUMB MECH
5LICENSEDCONraACroa'SDE LARATTON Job Description
I hcrehy alarm but I um T,o,c]atmer ntodt'iom,of cnapn,9 nnm,mm,oiog
ism Senionl100Pnf Uivi,inn 3nf the Bu,ine,x unJ l'mfcsinns C,de.and mYlic=mc
m i.in full lost and cRc=,
I.
zojs across, C_2_y Liax y CHIMNEY REPAIR
Date /lijd o,mmnnr_ -j4=i�lsshuy.
¢I s u y ANCIII'rECT'S UECI.ARAI' )N
a I undcr,lz duty pl:mx,hall he west n,pnhllo shad,
W7 Lico.,d 1'ndc„imml
(OWNER-BUILDER DECLARATION
I hereby affirm.ha.I um exempt from the Contractor's License Law for the
fallowing reason.(Section 9031.5,Business and Professions Code:Any city or county
+� O
whichporas 0 whichpermit1 ', , Itr, p cbmmi,lb.or raImi,ni,oruNtom
Prior , 111 -tl pplic t lo-io,lificomhou Ile U,i,ord,menwat
a t 2E than iik"I'd pan—lona the I' '. rn I IfilConars,t r,I Law(Ch"" 1) Sq. Ft. Floor Area Valuation
proamucit,inji,ahSca ]01l DiM,ion 3oflha llb,iro,mudI l ..innsC'so
or that he is exempt than fmn,and the basis for the alleged exon lio.,Any vichnin
af
of Section 7031.5 by any applicant fora pc.,it kjttm meapplicannn a civil pcnahy ant APN Number Occu
of not marc than five handed dollars($510), p
ylrqF
❑1.a,ownerofpropany,nrmyemploy,,will,wage,a,meh Nomcompemmlon.
will do Pm work.actio,hu,mmwrc is not a no chU,cd or c Lawl far,uoi(9w. loo4.n
owner of pro erty Who
lb Codc'1'Im mvns I mr',Llmnm Law docs nn,apply m un a lied InSpeCtI0I1S
oxoa of property lVno build,or itnpnn that such and who Ines such work himself
or through his......loyees.provided that such itnpm IS sol ere not intended ar
offered for ae.If,owner-milder
however,the Wading or immnofinem n sola within not year or 101 — FOUNDATION
nnpletioit the owncrbuildcr rill have the M1nNan of proving thin he did not build or
mpn,vefarpmpn,eor.w=.). .;,12 — CHIMNEY RERRR R• STRAPS
o1,a,nwnerorlheproparty.arae,,m„val...naracing wit,fieco,cdcommnm,m 514 — FINAL PUBLIC WORKS
construct the project(Sec.nwa.Poanos,and PrnreWono Coden'fhe Cmmmnora
License Law does not apply it,an omncr of pngeny who Wild,or improves,hereon.
and who contmu for such projects with a commcton,)licensed function to the
Comowuo'a Licen¢Ism.
❑1 am usempt under Sea .R k P C for this mann
Owns' O
WORKER COMPENSATION DECLARATION f/
I hereby of cin under penalty of Perjury one of the following Jcclaratione
1 I have and rill maintain it Cenificam of Consent a, ,df-inwre for Worker'.,
'......nion, ts, prnvidcd fur by Swoon 371x1 of the Labor Gde, I'or the V
1c,
r'ban,ro.n1'the work lin whkh Ibis panni.Is lo,ucd,
}I ham and will maintain Worker's Comlenxmion Insurance.a.,required by Section
00 of the labor Calc,for the perfomsarim of the work for which this permit is v
sued.MyQQW �kke�h��Cnmpen^,JI��I�nve�aIr).�nm everter andel PPulllicy mm�{/h.,ee,are:
arrier:_ij(xJr'IGOS'I'1(, ON I IiXIiM1410NI f1M W�7"tti'
CC1I!!�I11TT�111 Cohl1'IiNSAI'ION INSURANCE ,
(I his,action need no,he cmad0ol if.)m permit is bottom hundred dollars
IS 100)Lir la,,.)
I cantly that in the porto r ancc of the work lo,voich this pcmal i,l"Umd,I
'hall no,employ any person itt any mannar no to w hecomu I.b.1(n the.4Vudery
Comp,"'alio Law,of CaUlfI ra Dam
Applicant
NOTICE'I O APPLICANT.11.after making this Cenificae nl Esen,ption.you should
become subjectn the Workers Compensation peation Promotion of the l Coale.you must
Q Q
fonhwithcomply%th such poo,m msorthi,permit shall ha
cdenedvo
aked.
CONS'T'RUCTION LENDING AGENCY
a I hcrehy alEm,.hw there h u cunn,nte.inn India,agency Iia the pcitinunmce
of the work for which Chir Tenni.h,,rood Si,,.30s)].Civ.C.)
t1Q Lcndcr's Name
= 7 Lcndd,Address
V Q I«nify,hat 1 have rend this application and,tme man he oMrve infonnmion is
correct. agree to comply with td1 city tmd enemy Iranian., nt
un.,and uo low,relating
QC.) Ihuildin,,onarardon.trodboobyauthor..ropresenm.....of I,i,ahy lorI,cr.Pan
W ,he aWvonmotioned progeny l...... 'inn Purry„u,.
t}. 6 (We)agree(none.indcnmify and keep harula"d,e Cill o.Criloinn aloin,.
J) liabilities,judgments,Co,.,and expenses which may in any way a=crue again,said
U Z
Cil)to consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �' /�1ti7.y5x<.cDatc
SOURCE REGULATIONS.
Noncom it Applicano/Couloactur Da,a Re-rool's -
DAZARDOUS MADiR1ALS DISCLOSURE
Will the applicant or future Wilding oecup:.nt.,ore or hamlle Iiardou,material Type of Roof
as defined by the CuNuima Municipal Code,Chapter 9.12.and the Health and Safety
Cod!,Scalon 25532(u)'l
❑Yam LGN^ All roofs shall be inspected prior to any roofing material being installed.
wiutheapplicnu.o,Ettmcbuilding ocanpmnu,oagtdpmcmmdc�rc''hich If a roof is installed without first obtaining an inspection, 1 agree to remove
emit humnlous air cma:mdnam,as defined by the Pay Area Air Gaanty Manage,ncm
Ii, a (O No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the hazardous materials mquimncros under Chapter r�95 Ell the I1^
CalifornialIlcold, Safety Co,lu,S=CII,moma.05at I,i,
I.11 25534.IUWcr,:md O,at
ihhu building due,not fumm,ly h,venmtwn.,Ih.n i,hmy rc,pominility,o naily.he
tccutcon ca f the requim on"which talus,be nm,prior.0 tuna ,n o f o Ceniflcam of
Occatun=>'' Signature of Applicant Date
All roof coverings to be Class "B"or better
Owncrnr as cut Da¢